Upheld, recommendations

Summary

Mr C, who is a prisoner, complained to us about the board's handling of his complaint to them about healthcare issues. We were satisfied that the board had considered and responded to the issues Mr C raised, but our investigation found that they had failed to deal with the complaint within the timescales detailed in their complaints procedure and had not kept him advised of progress.

Recommendations

We recommended that the board:

• apologise for the failures we identified in the handling of the complaint; and
• remind staff of the need to work in accordance with the NHS Scotland complaints procedure.

Summary

After Mr C’'s daughter (Mrs A) experienced several episodes of breathlessness, she was seen by her GP, who concluded she had a virus. Over the following days, Mrs A remained breathless. She collapsed at home and her GP was called out. He found that her blood pressure was low, but rising. He concluded that she had had a vasovagal episode (a temporary loss of blood to the brain) but was improving. Mrs A had further collapses over the following days and was eventually taken by ambulance to hospital. Shortly after arriving there, Mrs A collapsed again and, despite attempts to revive her, she died. Mrs A was found to have had a pulmonary embolism (a blockage in the artery that transports blood to the lungs). Mr C complained that there was a lack of urgency from accident and emergency (A&E) staff in diagnosing the cause of his daughter's symptoms. He also complained that Mrs A was left alone in a cubicle and that he and his wife were not allowed to sit with her.

After taking independent advice on this complaint from one of our medical advisers, we upheld Mr C's complaints. We found that Mrs A was seen by a nurse immediately on arrival at the hospital. However, she asked to use the toilet and was allowed to do so, which delayed triage (the process of deciding which patients should be treated first based on how sick or seriously injured they are) by around 30 minutes. Mrs A was triaged by a nurse and was prioritised as 'urgent', meaning she would be seen by a doctor within one hour. Our adviser said that Mrs A's symptoms were sufficiently abnormal to merit being prioritised as 'very urgent', which should have resulted in a doctor seeing her within ten minutes. Mrs A collapsed around twenty minutes after triage. We were satisfied that Mrs A was treated appropriately following her collapse, but we criticised the board for failing to identify the seriousness of her condition. Although we found it appropriate for Mrs A to be given privacy to use the toilet, we were also critical that Mrs A’s parents were not allowed to sit with her in the cubicle, or that staff did not ask Mrs A whether she wished to be visited.

Recommendations

We recommended that the board:

• apologise to Mrs A's family for the issues highlighted in our investigation;
• share this decision with staff carrying out triage in A&E with a view to ensuring an appropriate combination of tool-based prioritisation and professional judgement;
• take steps to ensure that the Fife Early Warning system (a system based on observation, and used to monitor changes in the patient’s condition) is being properly implemented and understood by staff in A&E;
• take steps to ensure that the triage process and decisions reached regarding treatment priority are properly documented; and
• remind nursing staff of the Nursing and Midwifery Council guidance on standard of conduct, performance and ethics 2008.

Summary

Mr C complained on behalf of his partner (Ms B) that the care and treatment provided to her late mother (Mrs A) was inappropriate. Mrs A, who lived in a care home, was admitted to hospital where she was diagnosed with pneumonia and treated with intravenous antibiotics (drugs to fight a bacterial infection, delivered straight to the patient's vein). Mrs A was discharged to her care home three days later with antibiotic tablets, but died suddenly in the early hours of the following morning.

Our investigation included taking independent advice from two of our advisers, a medical adviser and a nursing adviser. The medical adviser said that Mrs A's condition had improved while she was in hospital. Because she was returning to a care home, it was reasonable for the hospital to consider discharging her. However, there was clearly a lack of discussion with the family and the care home about Mrs A's ongoing care. Ms B was not aware that her mother had been in hospital until the care home phoned to tell her that Mrs A had died. The medical adviser was also concerned that there was a lack of communication with Mrs A about her treatment, including a medical decision not to attempt resuscitation if her heart or breathing stopped (DNACPR). There was also no evidence that Mrs A's mental capacity had been appropriately assessed. The nursing adviser said that there was a lack of communication between nursing staff and Mrs A's family and her carers in planning for her discharge, and a general lack of detail in the nursing notes.

Recommendations

We recommended that the board:

• ensure that relevant staff reflect on the medical adviser's comments in relation to the assessment of patients who lack mental capacity to make complex decisions about their care and treatment;
• issue a reminder to relevant staff of the requirement to keep clear, accurate and legible records;
• ensure that relevant staff reflect on the medical adviser's comments in relation to the completion of the DNACPR form;
• provide evidence that relevant staff have reflected on the specific reasons why there was a failure to communicate with the patient and her family; and
• apologise to Mr C and his partner for the failures identified during this investigation.

Summary

Mr C complained that the university had not followed their policy and procedures in dealing with his complaints that another student had bullied him, and that the university had failed to protect him. He also said that the university had not observed their 'dignity and respect' policy in dealing with his complaints and had not considered his mental wellbeing or provided the support he needed.

Our investigation found it unreasonable that the university did not respond appropriately to Mr C’s complaints. They told us that they had not replied because they considered the matter to be a personal one that was outwith their area of responsibility. We also found that they did not respond when Mr C repeatedly told them that he was attending counselling, that he was not coping, and that he was experiencing detrimental effects of his prescribed medication. We found this unreasonable too, and upheld Mr C's complaints. We also found that the university had not tried to offer early mediation, as they should have done, and had not considered how to deal with the information Mr C gave them, and its potential impact.

Recommendations

We recommended that the university:

• apologise for not addressing the initial complaint of bullying;
• remind staff of the importance of early intervention through mediation in cases of harassment and bullying;
• consider whether the recommendation they made regarding placement could have implications for discriminatory practice;
• apologise for failing to follow their policies and procedures and to take reasonable measures to address additional support needs and mental health wellbeing;
• make relevant staff aware of our decision letter and its findings; and
• consider arranging appropriate training for all staff on the mental health and wellbeing policy.

Summary

Mr C's daughter was not making the required progress on her college course and was transferred to part-time attendance. Mr C complained that the college had not taken action to resolve the academic difficulties she was having. The college investigated and did not uphold his complaint. Mr C considered that the college had not dealt adequately with his complaint when the college decided that his daughter had not made successful progress on part-time attendance to continue her studies. He said that when he asked how to appeal this, he was given conflicting information and told that he had exhausted the internal procedures.

We upheld Mr C's complaint, as our investigation found that, although the college had carried out a proportionate investigation, made a reasonable decision about his daughter's progress, and had tried to support her in her studies, they had not handled his complaint well. Neither had they clearly communicated with him in terms of the complaints procedure and other information.

Recommendations

We recommended that the college:

• apologise to Mr C for not adequately handling his complaint; and
• share our decision letter with relevant staff.

Summary

Ms C complained about a delay in Business Stream issuing their first invoice. Although Ms C’s company had occupied the property for several years, Business Stream issued their first invoice in May 2013, and backdated it to October 2010.

When the non-domestic water industry was opened up to competition in April 2008, Scottish Water became the wholesaler and businesses were required to purchase their water through licensed providers. Business Stream are the default licensed provider and Scottish Water passed Ms C’s details to them in October 2010. However, Business Stream did not identify Ms C as the occupant until an internal audit of April 2013, despite their representative having visited the site in December 2012. The representative had logged the site as being vacant.

We noted that Ms C may not have known that Business Stream were the default provider before they contacted her. However, we also considered the responsibilities on both parties. This is because Business Stream have a legal duty to collect water charges - which they can legally backdate for up to five years - and so their delay had to be weighed up against the fact that Ms C could have contacted them.

We upheld Ms C's complaint as we found that the evidence did not indicate that Business Stream had taken any significant steps in relation to her premises, despite Scottish Water giving them her details in October 2010. Although the evidence indicated that they acted promptly to identify and send their invoice to Ms C after their 2013 audit, we considered that, on balance, they took an unreasonable length of time to issue a first invoice.

Recommendations

We recommended that Business Stream:

• apologise to Ms C for the delay in issuing their initial invoice; and
• confirm that steps will be taken to ensure that, when their staff contact customers who are yet to be invoiced, they explain that invoices will be backdated (where relevant).

Summary

Mr C complained that in March 2012 his business unexpectedly received water bills for more than £2,000. He had understood that the business's water usage was paid for through his service contract with the landlord. However, Business Stream confirmed that in March 2011 his premises had been identified as a gap site (a site that has never been billed for water). Mr C applied for reassessment of his business's water charges so that they would be estimated based on the number of staff and facilities in the building, rather than its rateable value. His bills then reduced significantly, but he complained that Business Stream refused to backdate the reassessed rate. He felt that this should be done, saying that Business Stream's failure to contact him between March 2011 and March 2012 prevented him from applying for reassessment earlier.

We found that there had been a delay of around seven months before Mr C's premises were confirmed as a gap site. At that stage, Scottish Water should have issued a letter to advise the occupant that a water account should be set up with a licensed provider so that water services could be paid for. Although we were told that a letter was sent to the premises, we were provided with no clear evidence of this. We noted that the building had multiple occupants and that the letter may not have reached Mr C's business.

There was also a significant delay between Business Stream being made aware of the gap site and their taking action to start charging for water services. Mr C, however, also had a responsibility to advise a licensed provider that his business was in the premises and to commence paying for water services, but had made no such contact. Although we concluded that Mr C and Business Stream had a shared responsibility to make arrangements to set up a water account, we recognised that Mr C had clearly been prevented from applying for reassessment because of Business Stream's delay. During our investigation, Business Stream accepted this and offered Mr C an ex-gratia credit to his account, which we considered to be reasonable.

Recommendations

We recommended that Business Stream:

• apologise to Mr C for the delay in setting up his account and notifying him of the water charges accrued by his business.

Summary

Mr C, who is a prisoner, complained to the prison that they had failed to respond to an earlier complaint that he had submitted. The prison's internal complaints committee (ICC) upheld this complaint, and recommended that his original complaint should be logged and responded to in line with their procedure. Mr C then complained to us when the prison had still not responded.

The Scottish Prison Service (SPS) told us that when Mr C's complaint paperwork was returned to the administration office after the ICC hearing, the database was not updated to record the ICC recommendation. This meant that the relevant officer was unaware the recommendation had been made. The SPS assured us that the system in place at the prison for logging and responding to complaints was robust, and that the failure to deal with Mr C's complaint was because of administrative error. They said the staff involved had been reminded of the importance of logging complaints to ensure they could be tracked and responded to in line with the complaints procedure.

Since complaining to us, Mr C has now received a response to his original complaint. However, we upheld his complaint to us because the prison did not log or respond to his original complaint within the relevant timescale, and because they also failed to action the ICC's recommendation.

Recommendations

We recommended that the SPS:

• apologise to Mr C for failing to action the ICC's recommendation.

Summary

Mr C, who is a prisoner, was placed on report for having items in his pocket that he was not supposed to have. One of the items was a tablet that a nurse suspected was Mr C's prescribed medication. The prison tested it and confirmed that it was Mr C's medication. He was charged and punished at a disciplinary hearing. He said that he was told he could have the tablet independently tested, but was then told that the whole tablet was used in the testing process. Mr C complained that the prison inappropriately failed to retain the tablet so that he could have it tested.

In line with the Scottish Prison Service (SPS)'s drug testing policy, the prison should have completed a drug testing recording sheet and prepared a report for Mr C's disciplinary hearing. We asked to see that paperwork, but the SPS told us it was not available. They told us the approved drug testing kit was used and the result of the test was reported verbally to the adjudicator of the hearing. We asked them to confirm that prisoners were entitled to have substances that had given a positive result tested independently, and the SPS confirmed they were entitled to do that.

Mr C was denied the opportunity to have the tablet tested independently. The prison did not complete the required paperwork or prepare a report for the adjudicator. Because of that, we were unable to determine whether the prison correctly followed the process, and we upheld Mr C's complaint.

In addition, we noted that we had previously investigated a similar complaint (case number 201203443) in which we identified the same failings. At that time, we asked the SPS to remind all prison establishments of the obligation to follow the requirements of the drug testing policy, and they issued an action notice to all prisons in February 2013. In our decision on Mr C's complaint, we noted our disappointment that the same failing occurred in this case and made a recommendation relating to this.

Recommendations

We recommended that the SPS:

• review the circumstances of Mr C's case to decide whether appropriate corrective action should be taken;
• apologise to Mr C for not giving him the opportunity to have the tablet independently tested; and
• remind all prison establishments again of the obligation to follow the requirements of the presumptive drug testing policy.

Summary

Mr C, who is a prisoner, had his cell searched and items of property removed. He was told an investigation would take place but a few weeks later, Mr C was told the items had been destroyed. Mr C complained that the prison had inappropriately removed and destroyed property from his cell. He also complained that the prison failed to appropriately investigate the matter.

The prison told us they suspected Mr C was running an illegal 'shop' by obtaining items in an unauthorised way, which was why his cell was searched. They said the items removed were considered to be excessive for Mr C’s own use, and were thought to be from illegal lending, which backed up their suspicions. The prison rules confirm that the prison are entitled to search a prisoner’s cell and remove any items of unauthorised property. They are also allowed to destroy unauthorised or prohibited items. However, the prison gave us a copy of the process that should be followed by staff when removing items from a cell. This confirmed that staff should have kept a record of the items of property removed, which did not happen in Mr C’s case. Because they did not do this, Mr C was unable to prove that items may have belonged to him. In addition, the prison were unable to provide any evidence to show us that they had investigated whether the items removed actually belonged to him. It was clear the prison were allowed to remove the items from Mr C’s cell but they were only entitled to destroy unauthorised property. Mr C maintains the property was authorised but the prison disagreed. Because the prison failed to follow the correct process and retain a record of the items removed, there was no way to determine whether the items destroyed were authorised and we upheld Mr C’s complaints.

Recommendations

We recommended that the Scottish Prison Service:

• ensure prison staff are aware of the procedure that should be followed when searching a prisoner's cell; and
• remind prison staff of the requirement to obtain a record of items removed from a prisoner's cell following a search.